Application For Accessible Parking Space Program Driver Only Application (Page 4 of 4) in pdf

REVISED May 1, 2014 – Previous Versions No Longer Valid

Please check off any of the following medical conditions that accurately describe your patient’s disability:

 Lung Disease: Yes  No  

Does this require the use of portable oxygen? Yes 

No 

Explain:_____________________________________________________________________________________________

________________________________________________________________________________________________

 Class III or Class IV Cardiac Condition, according to the American Heart Association Explain:___________________

___________________________________________________________________________________________________

_________________________________________________________________________________________________

 Arthritis:

Type of Arthritis___________________________ Joints Affected:____________________________

Explain:_____________________________________________________________________________________________

________________________________________________________________________________________________

 Other mobility impairment that requires the use of a medically necessary mobility device (wheelchair, scooter,

prosthesis, walker or cane). A prescription for this mobility device must be included.

Explain:_____________________________________________________________________________________________

________________________________________________________________________________________________

Physician’s Name (printed clearly)___________________________________________________________________________

Name of Hospital, Clinic of Medical Practice __________________________________________________________________

Address of Medical Practice _______________________________________________________________________________

Phone Number: ___________________________________________

Email: ________________________________________

I hereby certify that the above information is true and accurate under the pains and penalties of perjury.

_____________________________________________________

_____________________________________

Physician Signature

MA Board of Registration Number

FOR APPLICANT – PLEASE HAVE THIS SECTION COMPLETED BY A NOTARY PUBLIC

Commonwealth of Massachusetts

Ss,____________________________________________________

County

Now comes _____________________________________________________, (name of applicant)

who personally appeared before me and swore the foregoing to be both true and accurate.

Printed Name of Notary Public _________________________________________________________

Signature___________________________________________________________________________

STAMP HERE

Commission Expiration Date: ______________________________

Notary Public must stamp this application

Application For Accessible Parking Space Program Driver Only Application Page 4